Is Histamine not involved in the pathophysiology of burn
induced vascular dysfunction in humans?
Joakim Johansson1, M.D., Emanuel Bäckryd1, M.D., Göran Granerus2
M.D., Birgitta Lönnqvist2 Engineer, Folke Sjöberg 1,3, M.D., Professor.
Departments of Anesthesiology and Intensive Care1, Clinical Physiology2
and the Burns unit, Hand and Plastic Surgery3.
Short title:
Adress correspondance to:
Joakim Johansson, M.D.
Department of Anesthesiology and Intensive Care,
Östersund Hospital
SE 83183 SWEDEN
Phone:
+ 46 63 153000
Fax:
+ 46 63 154501
e-mail:
joakim.johansson@jll.se
Abstract
The increased amount of extravascular water following burns is thought to contribute to
morbidity and mortality because it interferes with gas exchange in the lungs and tissue healing.
There has been much effort made to explore the underlying pathophysiological mechanism that
generates increased vascular permeability following burns. Many different substances have been
proposed as mediators of witch histamine is one. The reason for this is that early work showed
evidence of increased histamine plasma-concentrations and animal models pointing at histamine
as the mediator. Modern clinical studies investigating the possible role of histamine as a mediator
of postburn increased vascular permeability are lacking.
Therefore we investigated urine-levels of histamine and metylhistamine following major burns
in 8 patients.
We found no increase in urine excreation levels of histamine or its metabolite methylhistamine
even though the patients showed the characteristic signs of increased vascular permeability.
We conclude that this is evidence for histamine not being a mediator of increased vascular
permeability following burns in non burned areas. This study can not however exclude histamine
as a local mediator in burned areas.
Key words: burn, histamine, mediator, oedema, vascular permeability
Introduction
Extensive thermal injuries result in a massive inflammatory response with both local and
systemic effects which, if not alleviated, may lead to burn shock [1-3]. To be able to reduce these
deleterious effects of the inflammatory reaction, it is vital to understand the basic
pathophysiological mechanisms involved.
Histamine is one of the classical mediators of inflammation. Mast cells, which together with
basophils store most of the histamine in humans, are present in loose connective tissue, especially
around blood vessels. Mast cells are very abundant in the skin, the dermis containing 3000 - 12
000 mast cells per cubic millimetre[4]. Different stimuli can induce mast cell degranulation and
subsequent release of histamine such as: mast cell IgE-stimulation by antigen; anaphylatoxins;
several interleukins; physical stimuli like heat and cold; free radicals; and others [4-6].
Histamine mediates its effect through three classes of receptors: H1, H2 and H3. H1 receptors
are present in, among other tissues, endothelial cells, and, when stimulated induce (a): the
contraction of endothelial cells, leading to the formation of gap junctions and subsequent
increased vascular permeability and (b): the release of nitric oxide, prostacyclin and other factors,
leading to vasodilatation[4, 7, 8]. Vascular smooth muscle contains both H1 and H2 receptors
who mediate constriction and dilatation, respectively [4, 8]. However, the net effect of histamine
upon the vascular tone in skin seems to be predominantly vasodilatory [4]. Moreover, histamine
induces recruitement of leukocytes to sites of inflammation [5] and seems to enhance the
catalytic activity of xanthine oxidase, witch may lead to enhanced synthesis of oxygen free
radicals [9].
Histamine is considered to be an important mediator of burn induced vascular dysfunction,
especially in its early phase [1]. However, most of this assumption is based on animal
experimental models [6, 10]. Consistent data in humans are lacking [11, 12]. Results from animal
experiments may not apply to humans for different reasons, especially when considering the
inter- and intraspecies heterogeneity of different mast cell subpopulations [13].
This study aimed at describing the metabolism of histamine in humans during the first 48 hours
after a moderate to major burn.
Patients and Methods
The study was conducted at a tertiary referral university hospital in Linköping, Sweden at a
specialised Burn intensive care unit. Consecutively admitted patients were included.
In order to evaluate histamine metabolism, it is mandatory to measure levels of histamine
metabolites in addition to histamine. Urinary levels of histamine and methylhistamine were
therefore measured in 8 patients during the first 48 hours at the burn unit. Moreover, in one case,
leves of methyl imidazole acetic acid were measured.
On admission, the bladder was emptied (”pre-admission” urine). The urine was then collected
every 6 hrs for two days. Upon collection, the urine was immidiately acidified and the volume
carefully measured. A sample was kept and frozen. The samples were later analysed by reversed
phase ion-pair High Performance Liquid Chromatography (HPLC) [14, 15] at the department of
Clinical Physiology, Linköping University Hospital. The excretion levels were compared to a
healthy control group (n=20) from an earlier study of co-worker Granerus [16] using the same
method.
The urinary excretion of creatinine was also determined for each sample. Histamine and
methylhistamine levels were then normalized for creatinine excretion, thereby correcting for
differences in body size. Moreover, in 6 patients, day 1 creatinine clearance was determined.
Results
The mean extent of the burn (Total Burn Surface Area) was 23%, 11-37 (median, range), with
no mortality. For further patient data, see Table 1.
Pat 1
Pat 2
Pat 3
Pat 4
Pat 5
Pat 6
Pat 7
Pat 8
Gender
(M/F)
Age
(years)
Weight 0- TBSA (%)
24 hrs
postadmiss
ion (kg)
Transport
time to
burn unit
(h)
M
M
M
F
M
F
M
F
43
50
44
13
89
52
9
75
121
60
103
59
75
64
36
*
20
*
13
3,5
8
5
10
4
30
11
23
32
14
24
37
17
Time from
admission
to
operation
(h)
18
19
11
15
16
10
15
15
Mode of
injury
Scald
Flame
Scald
Flame
Flame
Flame
Flame
Flame
* No data
Table 1. Patient data.
The urinary excretion of histamine per 6 hours is shown in figure 1. Initially (0 – 18 hrs postadmission), the urinary levels of histamine were normal. During the period 18 – 30 hrs postadmission, there were increased variation in histamine-levels. This was largely dependent on
patient 1, whose histamine-levels were largely increased in these samples. For the remaining
observation period, we also found normal levels. There were no statistically significant variation
in histamine-levels within the patient group as tested with Kendalls coefficient of concordance.
The same result was obtained regardless of whether or not patient 1 was considered a statistical
outlier. Further, when levels were compared to healthy controls there were still no statistically
significant variation to be found.
The urinary excretion per 6 hours of methylhistamine is shown in figure 2. There were no
significant changes over time within the patient group and no significant changes as compared to
healty controls.
In Patient 1, the excretion of methyl imidazole acetic acid was also determined and was found
to be within normal range (data not shown). To further investigate the possibility of an early large
release of histamine immediately post-burn, we also determined levels of histamine and
methylhistamine in ”pre-admission” urine; these levels were not substantially elevated in
comparison to healthy controls (data not shown). Hence, we found no direct evidence of an early
systemic release of histamine immediately post-burn.
In 6 of the patients, we were able to calculate endogenous creatinine clearance at some point
during day 1. 4 patients had a moderatly lowered creatinine clearance (range 60 – 76 mL/min).
Patient 5 had a very low clearance (28 mL/min); this patient was 89 years old. Only Patient 1
had a good clearance (182 mL/min). Hence, despite adequate resuscitation and good diuresis, the
renal function does not seem to be optimal during day 1 post-admission.
The dynamics of u-creatinine adjusted histamine and metylhistamine are shown in figure 3 and
4 respectively. According to Kendalls coefficient of concordance there were no statistically
significant variation in the two variables during the time-period studied.
Discussion
The interest in the role of histamine in burns has a long history. In 1936, Barsoum and Gaddum
showed high and rising blood-histamine levels for days after a major burn [17]. Since then,
histamine has been considered to play an important role in the pathophysiology of burns,
especially in the early phase of postburn oedema [1].
Histamine is known to be potently vasoactive, as manifested by its alleged role in anaphylaxis
[18]. Hence, as animal experimental models have shown that histamine is released into the
plasma after a burn [9, 10], it is reasonable to hypothesize that histamine is being released from
human burned skin and may play a role in systemic burn induced vascular dysfunction. However,
evidence in humans is conflicting. In 1957, Birke et al demonstated high urine postburn levels of
histamine in humans[12], whereas Agrup and coworkers failed to confirm this [11]. Hence,
conclusive evidence for a huge release of histamine from human skin postburn is at best scarce.
Results from administration of systemic antihistamines postburn are conflicting. While the H2antagonist cimetidine reduces postburn oedema in animals [9, 19, 20], another H2-antagonist
(ranitidine) does not [21]. It is therefore likely that non H2-receptor dependent effects of
cimetidine are at work, e.g hydroxyl radical scavenging [9] or SOD-like activity, e.g. [21].
Antihistamine treatment aiming at reducing vascular leak are tested and found not effective [ref].
In all modern intensive care facilities however, pharmacological stress-ulcer prevention is
standard of care. Proton-pump inhibitors are the most often used drugs but histamine-blockers
may also be used for this purpose.
In this study, histamine metabolism was studied by measuring the excretion of histamine and
methylhistamine (a metabolite of histamine), and in one case methylimidazole acetic acid, into
the urine. As histamine is rapidly cleared from the plasma, urinary output levels is the most
reliable way to study histamine metabolism [18]. The kidney removes histamine from plasma
very effectively, the renal extraction ratio being aproximately 80% [22, 23]. Moreover, the
kidney has capacity to metabolise histamine. Only a few percent are excreted unchanged in the
urine [16, 18, 22, 24]. Consequently, to be able to evaluate histamine metabolism, it is mandatory
to measure levels of histamine metabolites in addition to histamine.
Urinary excretion of histamine and metylhistamine, as well as most other excretion products,
are affected by the fact that burn-patients experience extreme alterations in water content in
different body compartements. This alterations affects most of all the extracellular space with is
expanded following burns due to the large amount of intravenous fluids that must be
administered during the first 24 hours. The volume of distribution of all solutes in the body is
hence increased.
If patients are resuscitated according to the Parkland formula, witch is the most common
method to guide the initial fluid therapy, they often gain 10-15 % of body weight [behövs ref?,
Folke] during the first 24-48 hours. This was also true for our patients (redovisas eller ej, Folke?).
During the following days of intensive care it is common with an increased urine-production to
restore water hoemostasis. If there were an alteration in histamine- or metylhistamine-metabolism
it may be masked by these changes in water physiology.
Urinary excretion of creatinine is known to follow the excretion of histamine and
metylhistamine. To be able to compensate for the effect of altered water physiology we also
analysed urinary creatinine for every patient in every 6 hour-fraction of urine. We were then able
to calculate the fraction of excreted histamine/metylhistamine per amount of excreted creatinine.
This is the u-creatinine adjusted histmine and metylhistamine levels respectively.
Histamine can be synthezied in the kidney [25, 26]. Some studies suggest that the major source
of urinary histamine may be de novo synthesis in the kidney [25].
There was a tendency for increased urinary histamine and metylhistamine during the study
period. This tendency was seen largely because of patient #1 who showed a large increase. With
his data considered as statistical outliers there was no tendency at all for a dynamic change in
either histamine or metylhistamine during the first 48 h after admittance.
The patients were operated on 10 to 19 h after arrival. It can not be excluded that the trauma of
operation could lead to the second-day output of histamine seen in some of the patients, and seen
in other earlier studies, especially when considering that some drugs used in the perioperative
period (and also in the intensive care setting) can induce histamine release [27].
As described above, the bladder was emptied on admission. The content of histamine and
methylhistamine was analyzed in this sample as well. Due to the great range of transport time to
the Burns Unit (see Table 1) and due to uncertainty in urine collection during that period, it is
difficult to compare the excretion pre-admission. Nevertheless, there is no evidence of a huge
release of histamine during the pre-admission period (data not shown).
Other proposed mediators of increased vascular permeability following burns are serotonin,
prostaglandins and oxygen radicals, as reviewed by Arturson [1]. Most data rely on animal
studies and follow up in humans have not been convincing with regard to the involvement of the
respective proposed mediator. In recent years, increasing interest has been shown leukocytes and
the products released by them following severe physiological challenges such as burns, trauma
and sepsis [28, 29]. Our group has recently shown that neutrophils release heparin binding
protein (HBP) following burns [in press]. HBP has, in preclinical models, been shown to alter
vascular permeability [30, 31]
In conclusion; This study could not confirm a release of histamine from burned skin 0-48 hours
after a modrate to major burn. We conclude that histamine is unlikely to mediate the
increased vascular permeability in non burned tissues following burns. This study, however,
can not exclude a role for histamine as a local mediator of increased vascular permeability in
burned areas.
100
80
60
histamine
40
20
0
ctrl
6-12 h
18-24 h
30-36 h
42-48 h
0-6 h
12-18 h
24-30 h
36-42 h
time of urine sampling post-burn
Mean
Mean±SE
figure 1. Urinary histamine-levels in 8 burned patients compared to healthy controls. No
significant variation over the time period studied or compared to control-levels. Mean and
standard error of the mean (SEM).
140
120
100
80
60
metylhistamine
40
20
0
ctrl
0-6 h
6-12 h
18-24 h
30-36 h
42-48 h
12-18 h
24-30 h
36-42 h
Mean
Mean±SE
time of urine sampling post-burn
Figure 2 Urinary metylhistamine-levels in 8 burned patients compared to healthy controls. No
significant variation over the time period studied or compared to control-levels. Mean and
standard error of the mean (SEM).
Mean; Box: Mean±SE
300
250
200
150
100
u-creatinine adjusted histamine
50
0
0-6 h
figure 3 (alternativ 1)
12-18 h
24-30 h
36-42 h
6-12 h
18-24 h
30-36 h
42-48 h
time of urine sampling post-burn
Mean
Mean±SE
900
800
700
600
500
400
300
u-creatinine adjusted histamine
200
100
0
0-6 h
12-18 h
24-30 h
36-42 h
6-12 h
18-24 h
30-36 h
42-48 h
Median
25%-75%
Outliers
Extremes
time of urine sampling post-burn
figure 3 (alternativ 2) U-creatinine adjusted histamine-levels in 8 burned patients. No significant
variation over the time period studied.
600
500
400
300
200
u-creatinine adjusted metylhistamine
100
0
0-6 h
12-18 h
24-30 h
36-42 h
6-12 h
18-24 h
30-36 h
42-48 h
Mean
Mean±SE
time of urine sampling post-burn
figure 4 (alternativ 1). U-creatinine adjusted metylhistamine-levels in 8 burned patients. No
significant variation over the time period studied.
700
600
500
400
300
200
u-creatinine adjusted metylhistamine
100
0
0-6 h
12-18 h
24-30 h
36-42 h
6-12 h
18-24 h
30-36 h
42-48 h
Median
25%-75%
Outliers
Extremes
time of urine sampling post-admittance
Figure 4 alternativ 2
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